Frequently Asked Questions

What is the Affordable Care Act and what does it mean for me?

The Affordable Care Act (ACA) is the United States of America’s health reform law enacted in March of 2010. Also called “Obamacare” because it was signed into law by President Barack Obama, the ACA puts in place comprehensive health insurance reforms that will roll out over four years and beyond.

Some of the reforms under ACA include many free preventative services for most Americans, prescription discounts for seniors, and pre-natal coverage for women. Under ACA, no one can be denied a major medical insurance policy due to pre-existing conditions. Coverage is now available for children under their parents’ health plans up to age 26. ACA also required insurers to justify any premium increases of 10% or more.

The Affordable Care Act also required every state to create a health insurance marketplace (also called an exchange) or contract to use the federal marketplace. Individuals can go to these marketplaces to buy health insurance.

ACA also created requirements for all Americans to have health insurance coverage or face a tax penalty. There are many other aspects of the Affordable Care Act, and an agent can help you understand how the ACA effects your individual healthcare coverage.

What happens if I don’t buy health insurance?

Everyone is required by law to have health insurance coverage. Anyone who doesn’t is required to pay a tax penalty, unless they qualify for an exemption. For more information on exemptions and buying health insurance, click here.

What is “Open Enrollment”?

Open enrollment is the period of time during which individuals can buy ACA approved health plans. The open enrollment period to buy health plans is from November 15 through February 15 of the next year. In order to purchase health insurance coverage outside of open enrollment, you need to qualify for a special enrollment period. Click here to find out if you’re eligible.

How can I buy or change health insurance outside of Open Enrollment?

There are a number of qualifying life events that would make you eligible to buy private health insurance outside of Open Enrollment. Some events that trigger a special enrollment opportunity include:

Loss of eligibility for other coverage (such as losing your job or losing student health coverage when you graduate)

Gaining a dependent (such as getting married, giving birth, or adopting a child)

Divorce or legal separation

Moving to another state or within a state if you move outside of your current health plan’s area of coverage.

COBRA coverage ending

Losing eligibility for Medicaid or the Children’s Health Insurance Program

Change in immigration status

There may be other events which would qualify you for special enrollment eligibility. When you experience a qualifying event, you can enroll for 60 days from the date of that event. Click here to find out if you’re eligible.

Should I buy insurance through an agent?

Although you are not required to buy individual health insurance through an agent, it is highly recommended. An agent can help you find a health insurance plan which meets your needs as well as budget. Health insurance is an important and complex subject, and all plans are not created equal. Policies are often written in difficult legal terms that most people are not accustomed to reading. An agent can help you make sense of the legalese, so you don’t find yourself in financial difficulty down the road.

We provide our services free of charge to you. Based on the information you provide, we match you to a licensed agent who is contracted with several insurance carriers in your area that can meet your needs. Your agent will guide you through your decision- from quoting to buying. They’ll help you find out if you qualify for a subsidy, what the benefits of each plan are and what your actual costs will be. An agent will answer questions you may have about a carrier, a plan or new healthcare law. Online exchanges can only provide you prices of a few plans and options, while most health insurance agents represent all of the insurance companies available in your area. Our agents are able to quote plans both on and off the exchange, so you’ll have access to every option.

Whether you buy through an agent, a marketplace, or direct from a carrier, you will pay the same price. Premiums are regulated by the government, and insurance companies cannot charge you more for buying through an agent. An agent is paid by a commission, through the insurance company. Their commission is already worked into your premium, whether you buy through an agent or not, so it will never effect your price.

Basic services such as claims and policy changes will likely be handled much quicker through an agent. Rather than waiting on hold for hours to have a claim mistake corrected, ask your agent to help you with the situation. Chances are, the agent will get it done with less time and work on your part. Click here for a free quote.

What is a Health Insurance Marketplace or Exchange?

Health Insurance Marketplaces (also called Exchanges) are websites set up for individuals to buy health insurance. Each Marketplace features a number of insurance carriers, each offering different health plans. You can shop, compare and buy a health plan for you and your family. Premium and cost sharing subsidies are available through the Marketplace, based on income. Small businesses can also buy coverage for their employees through the Small Business Health Options Program (SHOP) Marketplace. Some Marketplaces will be operated by the state, while others will use the federal health exchange. The terms “on exchange” and “off exchange” refer to health plans either available or not available through a Marketplace. Our agents are able to sell plans both on and off exchange. Click here for a free quote.

Do I have to buy a health plan on the Marketplace or Exchange?

No. The Marketplace (also called the Exchange) is just one of the ways people can shop for individual health insurance. Our agents have access to all health plans, both on and off the exchange. Click here for a free quote.

What kind of health plans are available under the Affordable Care Act?

There are four basic plans categorized by metallic levels: Bronze, Silver, Gold and Platinum. These four new metal plans are differentiated from another by their actuarial value. Actuarial value refers to the average amount of expenses that would be paid for by the member.

The higher the actuarial value of a plan, the lower the out-of-pocket costs for the plan member. A Bronze plan covers 60%, Silver 70%, Gold 80% and Platinum 90% of insurance costs. It follows the average premium will be lower for the lower metal plans, and higher for the higher metal plans.

What health benefits are now provided?

For individual health plans, there are 10 broad categories of medically necessary services covered (also called the 10 essential health benefits) under ACA:

Ambulatory patient services (outpatient care)

Emergency services

Hospitalization

Maternity and newborn care

Mental Health services (including substance abuse)

Prescription drugs

Rehabilitative and habilitative services and devices

Laboratory tests and services (including X-Rays)

Preventive and wellness services, as well as chronic disease management

Pediatric medical services (including both oral care and vision care)

What is a subsidy, tax credit and cost sharing reduction and how do I qualify?

A subsidy is financial assistance from the government to help people pay for their individual health insurance. There are two kinds of health insurance subsidies: an advanced premium tax credit and a cost sharing reduction. Some people may qualify to receive both types of subsidies.

Under the ACA, advanced premium tax credits can be used right away to lower monthly premium costs. If you qualify, you can choose how much is applied to your premium each month. If your yearly amount of advance credit is less than the tax credit you're due, you’ll get the difference as a refundable credit when you file your federal taxes. If your advance payments for the year are more than your credit, you must repay the excess with your tax return.

A cost sharing reduction reduces your out-of-pocket maximum. This amount is the most you'll have to pay during a policy period for health care services you receive and includes your deductible, coinsurance and copays. It usually doesn't include premiums, out of network charges, or the cost of non-covered services. The "out-of-pocket" payment varies among healthcare plans.

An agent can help you find out if you are eligible for a tax credit or cost sharing reduction. Several factors go into qualifying for a subsidy, including income, your family size, and how much health insurance costs on average in your area. It only takes a few minutes for an agent to find out if you qualify for a subsidy. Click here to find out if you qualify.

How can I find if my doctor is in a health plan’s network?

Most managed care programs have a site which lists the doctors, hospitals and/or facilities included in the PPO or HMO network. Agents also have access to a list of providers in every health plan, so he/she can look up your doctor for you. Click here to speak with a licensed agent.

How can I find out if a health plan covers my prescription drugs?

Most managed care programs have a site which lists the prescriptions covered in each health plan. This list is called a “formulary”. Agents also have access to each health plan’s formulary. Click here to speak with a licensed agent.

What is a Premium, Deductible, Coinsurance, Co-pay, and Out-of-pocket expense?

A premium is the amount that must be paid for your health insurance plan. It’s usually a monthly, quarterly or yearly bill.

A deductible is the amount on top of your premium that you are required to pay before your health insurance carrier begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services. The deductible may not apply to all services.

Coinsurance is the percent that the insurer pays after the policy’s deductible is exceeded. So it’s your share of the costs of a covered benefit. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, 20% coinsurance payment would be $20. The insurance carrier pays the rest of the allowed amount.

A copayment is a fixed amount you pay for a covered health care service, like a doctor’s visit, usually when you get the service. For example, if you have a $15 copay, you pay that to the doctor, and your health insurance carrier is billed for the remainder of the bill.

Out-of-pocket expenses are costs for health care that aren't reimbursed by insurance. Out-of-pocket costs include all of the above expenses (deductibles, coinsurance, and copayments). All health services not covered by a plan are considered out-of-pocket costs.

What is an HSA?

A Health Savings Account (HSA) is available to tax payers enrolled in a High Deductible Health Plan. A High Deductible Health Plan generally has a lower premium, so the money that you save monthly can then be put into the HSA. HSAs enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. If you withdraw funds for any reason other than qualified medical expenses, the money will become subject to both income tax and a ten percent IRS penalty. (There is one exception, when you become 65 years of age or older, you may then withdraw the money without penalty. The withdrawal will still be subject to income tax.) The money in the HSA account rolls over from year to year, and it’s your money- you control it.

What’s the difference between an HMO and a PPO?

A Health Maintenance Organization (HMO) is a type of health plan that limits coverage to a network of doctors who work for or contract with the HMO. An HMO won't cover out-of-network doctors except in the case of an emergency. Most HMO plans require patients to have a primary care physician, who then refers the patient to see specialists. HMOs often require members to live or work within its service area.

A Preferred Provider Organization (PPO) is a health plan that contracts with providers like hospitals and doctors to create a network. Providers in the plan’s network are less costly. Patients can use providers outside of the network, but for an additional cost. PPOs do not require patients to have a primary care physician.